Waters Of Dunkirk Skilled Nursing Facility, The
WATERS OF DUNKIRK SKILLED NURSING FACILITY, THE in DUNKIRK, IN — inspection on March 30, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
155571 03/30/2026
Waters of Dunkirk Skilled Nursing Facility, The 11563 W 300 S Dunkirk, IN 47336
During an interview on 3/26/26 at 2:43 p.m.
Registered Nurse (RN) 16 indicated QMA 7 reported to her that she observed Resident B performing oral sex on Resident C and told Resident C to leave the room.
When QMA 7 reported the observation, RN 16 did not report it to anyone.
She made a behavioral note. At the time, they had been told that it was okay for the residents to have a sexual relationship.
During an interview on 3/27/26 at 10:20 a.m., the Administrator indicated she did not report the incident between Resident B and Resident C to the State Agency until the day after the incident. RN 16 reported the incident to the DON the following morning and then the DON reported the incident to the Administrator. A current facility policy, titled Abuse Prevention Program, provided by the Administrator on 3/30/26 at 10:36 a.m., indicated the following: .Abuse Reporting Policy .Procedure .the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred.
The Charge Nurse will immediately report the incident to the Administrator .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately.
State Licensing and Certification Agency (i.e. ISDH) This citation relates to Intake 2962257.410 Indiana Administrative Code (IAC)16.2-3.1-28(c)
155571 03/30/2026
Waters of Dunkirk Skilled Nursing Facility, The 11563 W 300 S Dunkirk, IN 47336
B and Resident C started talking.
The facility resolved care plans after speaking with the Ombudsman
C was redirected, he was aggravated and asked why he could not talk to the female resident. He held
staff completed behavior tools and then she would put a note in Point Click Care (PCC).
The behavior sheets were located in a behavior tool folder at each nurse's station.
The CNAs were unable to read the care plans in PCC but could see the behaviors on the behavior sheets.
Resident C was on medroxyprogesterone, and psychotropic behavior monitoring would be located on the Medication Administration Record (MAR).
The DON or ADON added the psychotropic monitoring to the MARs.
The behaviors were reviewed monthly.
The behaviors were a fine line between being appropriate or infringing on their rights.
The Ombudsman indicated it was an infringement on their rights, there BIMS score did not matter and as long as their BIMS score were similar.
The SSD felt that if a resident had a BIMS of 15 (intact cognition) and another resident had a BIMS score of 3 (severe cognitive impairment) that would be inappropriate.
She felt the residents had the mental capacity to consent to sexual behaviors but maybe not physically.
They did not currently have an assessment for sexual behaviors.
Behavior sheets were reviewed on 3/30/26 at 10:27 a.m. and indicated the following:Resident B had no behaviors that were monitored.Resident C had behaviors related to irritability with other residents, increased episodes of anxiety which included indicating that he missed a flight, had an appointment which he was late for, and he searched for his family member.
Interventions included providing reassurance, calling family, and offering him a cup of coffee or ice cream.
Resident D had no behaviors that were monitored.
Resident E had no behaviors that were monitored.
Resident F had behaviors related to increased anxiousness, asking where her daughter was and what she should do, and pacing.
Interventions included calling her daughter, providing one on one, assessing Activities of Daily Living (ADL) needs and talking about where she grew up. A current facility policy, titled Guidelines for Behavior Management Meetings Psychotropic Medication (Behavior Management Meetings), provided by HFA 2 on 3/30/26 at 10:36 a.m. indicated the following: Policy .These meetings are held monthly or more often as needed.
The purpose is to review residents who have behaviors and who are being monitored for these behaviors.
Further, to discuss and review residents who have newly developed behaviors to ensure that all appropriate interventions are in place to manage the behaviors with non-pharmacological interventions or the least dosage of psychoactive med(s) possible to promote and maintain the highest degree of psychosocial well-being and quality of life .
Roles-Responsibilities .Nursing .2) Monitors for presence of target behaviors on a daily basis and documenting same . 5) Assist in developing behavior care plans .Social Services 1) Maintains a list of residents with behaviors .5) Assists in behavior care plans This citation relates to Intake 2962257.410 Indiana Administrative Code (IAC) 16.2-3.1-43(a)(2)
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUNKIRK, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WATERS OF DUNKIRK SKILLED NURSING FACILITY, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.